| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
119 |
$8K |
| D1110 |
Prophylaxis - adult |
279 |
276 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
69 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
256 |
255 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
127 |
127 |
$4K |
| D4355 |
|
111 |
111 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
191 |
190 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
157 |
$3K |
| D0274 |
Bitewings - four radiographic images |
133 |
131 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
281 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
167 |
$864.35 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
15 |
$753.72 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
12 |
$459.56 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$194.04 |